Tuesday, May 25, 2021

Out of the Crisis #27: Eren Bali of Carbon Health on public health, COVID vaccinations, and working as a unified society to solve problems

Eren Bali arrived in Silicon Valley from Turkey in 2010 hoping to relaunch Udemy, his online education company. He spent a few years working at the tech startup SpeedDate before following through with his original plan, after which Udemy went on to be enormously successful. When his mother became ill and Eben spent some months accompanying her to doctors in order to get the right diagnosis and treatment, he had a realization that led him to his true mission.
"I just directly observed that the technology for doctors was really far from what they needed to operate at a high productivity level," he told me. "And that idea stuck in my head--that the largest, the most expensive resource of any country was one of the worst utilized." His first instinct was that "somebody" should rethink how a doctor operates, how they communicate with the patient, and basically how the whole concept of care delivery works. Then he realized that somebody was him.
Now, as CEO and founder of Carbon Health, Eren is leading one of the country's fastest growing healthcare startups. It's mission is to provide really high quality healthcare to the entire population, with a special focus on underserved demographics. A provider of low-cost health clinics across the country, Carbon Health was also on the frontlines when the COVID pandemic hit--and even understood what was coming long before most people in the U.S. did. They pivoted to monitoring patients for COVID, then testing. Ultimately, the company partnered with the City of Los Angeles, and as Eren recalls, "seven days after the original handshake and launch into a scheduling website, we helped launch Dodger Stadium, which was the single largest mass vaccination site in the country." From there, Carbon Health fully reinvented themselves as a full-stack public health company.
Eren and I talked about why, when so many companies shut down in the face of the crisis, his "decided to just go to the other direction." We also discussed what it was like to arrive in Silicon Valley, why a private startup ended up playing such a vital role in the vaccination rollout, and what the fact that it did says about the future of public health, public private-partnerships and the civic fabric that we all inhabit. We also discussed the role every citizen can play in fighting the pandemic "at a time when "more people are getting medical advice from Joe Rogan than Fauci." 

You can listen to our discussion on Apple, Google, or wherever you like to get podcasts.


A full transcript is beneath the show resources below.

Highlights from the show:

Eren introduces himself and talks about his background (3:34)
Coming to Silicon Valley and Speed Date (5:08)
Eren's first impressions of Silicon Valley (7:17)
The differences between Silicon Valley and other places as he immersed himself in the culture (8:48)
Moments he felt he didn't fit in (10:53)
Eren's words of advice for Turkish listeners (12:01)
Entering the Silicon Valley state of mind (13:15)
Eren on using Lean Startup to launch Speed Date before Lean Startup was known (14:45)
Building Carbon Health and the Minimum Viable Product version (17:21)
Translating leadership from one context to another (19:04)
How Eren decided to pivot to healthcare (20:04)
The sketch he made in 2013 that led to Carbon Health (22:20)
How he decided he was the one to take on the problem (24:59)
Carbon Health's mission (26:25)
Carbon Health's position just before the pandemic hit (28:09)
Eren's mindset as he became aware that COVID was spreading but most of the US was not (31:15)
Some of the "crazy ideas" Eren came up with that ended up being implemented (34:51)
How Carbon Health became a critical part of the vaccine infrastructure and response (37:34)
Partnering with local government for a fast vaccine rollout (39:29)
Reconfiguring Carbon Health's platform for vaccine distribution (40:39)
What Eren thinks it will take to get to herd immunity (43:08)
How everybody can mobilize to help now (47:33)
Uniting to solve the problem (48:25)
On not leaving the job half-done (52:22)
Balancing Carbon Health's core business with its Covid response (54:35)
The future of public health in America (56:23)
Problems for founders to consider taking on (58:47)
The long-term impact of the pandemic (1:00:39) 


Show resources: 

Transcript for Out of the Crisis #27, Eren Bali


Eric Ries: I'm Eric Ries. This is Out of The Crisis. It's been a long 18 months, hasn't it? And during that time we have seen it again and again: unlikely people thrust into the spotlight for their work fighting the pandemic, and even more, tirelessly working away out of the limelight. One such person is Eren Bali. However, if you went back in time and told Eren a few years ago that he would one day be at the center of one of the largest public health responses in history, I don't think he would have believed you. Eren came to the US from Turkey to work at a Silicon Valley tech startup, which is actually where I first met him a few years ago. But now as CEO and founder of Carbon Health, Eren is leading one of the fastest growing healthcare startups.

Carbon Health is a provider of low-cost health clinics across the country. As you'll hear, COVID arrived unexpectedly and directly on their doorstep. They had to decide whether and how to respond. What happened next was entirely unexpected, even by those of us who've admired Eren for a long time. Carbon Health is now running some of the largest vaccination sites in California, most famously at Dodger Stadium, in partnership with the City of Los Angeles. During the pandemic, Carbon Health fully reinvented themselves from an affordable care provider into a full-stack public health company. This raises the question: how did Eren go from building apps on top of Facebook to ensuring that hundreds of thousands of Americans got their vaccines? We've seen this story before, even on this podcast with stories like Curative. Why did a private company, a startup, wind up playing a vital role in the vaccination rollout? What was it about Carbon Health that made them ready and able to step into this vital civic responsibility? What can this tell us about the future of public health, about public private-partnerships and about the civic fabric that we all inhabit?

In this conversation Eren and I talked about his journey from a small town in Turkey to founding the education startup Udemy, also quite successful, to Carbon Health and eventually Carbon Health's vaccination efforts. Eren spoke openly about his growth as a founder and leader, as well as gave candid advice for future founders. His number one takeaway is one we have heard again and again. Put the mission first, think long term, and everything else will fall into place. Here's my conversation with Eren Bali.

Eren Bali: My name is Eren Bali. I'm the founder and CEO of Carbon Health. We are a technology enabled healthcare provider, and most recently we have been helping the vaccine rollout and we run some of the largest mass vaccination sites in the country, including Dodger Stadium in Los Angeles. Before Carbon Health, I was the founder and CEO of Udemy, which is now the largest online education platform in the world.

ER: Eren, thank you so much for coming on. How have you been? How's your family? How's your team? How have you been weathering the storm?

EB: I think I have been doing fine because of Carbon Health. We have been really the front lines of the pandemic. When you're very busy with something it's actually like, it  helps you stay strong. I have three small toddlers. I mean,  that’s a lot when working from home quite a bit.

ER: I know the feeling. Share a little bit about your background. You've done some really, really interesting things in the tech industry, including going back to when we first met, but I also think it's not the usual path people would imagine to running a healthcare company. So, talk a little bit about your background. How did you first get into tech and come to Silicon valley?

EB: If you go really back, I was born in a small village in South-east part of Turkey. That's the kind of lowest income part of the country, which had a lot of accessibility issues. So, I grew up where we had all the one teacher for the entire school, rotating between classes. Where healthcare education access was really limited. So, was the 80s, and I was able to break out of it because I was very interested in mathematics, and to everyone's surprise, ended up winning the silver medal in the International Math Olympiads, which was one of the first time somebody from the Eastern part of Turkey had really participated and won a medal.

But the main reason this happened in my mind was that the access to internet really made a big change in my life, because even when you're in the place of lowest access to education having access to other people online, mathematic problems, it allowed me to self-study. This innovation would not be possible probably 10 years before. So, I studied computer science and mathematics in Turkey and then decided to start a platform for everyone to be able to teach online. But, I was really inspired with platforms like YouTube and Blogger, and I thought somebody should have, should do the same thing for online education, and started the company in Turkey first. That didn't work. I shut it down.

We had to move to Silicon valley. So, it was a really long story. I guess it took three, four years to get Udemy off the ground. But yes, I migrated from Turkey to Silicon Valley in 2010 and started Udemy. But before that, actually,  there was this a couple of years break where, when Udemy did not work in Turkey, I met this Silicon Valley entrepreneur who wanted to build online, like speed dating, a video-based speed dating application. So, we actually took the original live customer application, converting their live video dating application. So, that's how I came to Silicon Valley in the first place.

ER: I remember Speed Date. That's one of the very, very early companies that I was talking to Lean Startup about. What was that, 2009, 2010?

EB: Yeah. I think it was 2009 and 10.

ER: Yeah. Wow. That was, that's a blast from the past. Say a little bit about what drove you to want to come to Silicon Valley in the first place.

EB: Honestly, I wasn't even aware of Silicon Valley or this whole concept of startups and tech companies until 2005. I thought these were just websites built by some amateur hobbyists. So, I was really interested in programming, design development, but I didn't  realize the kind of business aspect for a very, very long time. When we started at Udemy, in Turkey in 2006 and 2007, there was no funding available. Eventually I started working at nights as a contractor for Silicon Valley companies as a way to fund a project in Turkey. Then eventually, they asked me to come to Silicon Valley and maybe just work in person, and then while I was visiting Silicon Valley, I realized that there was this complete new world of technology companies. They are businesses. They're professional, and they do things differently. So, I got involved. I went back and forth and eventually I realized that to really build the vision we had for Udemy, we had to be in Silicon Valley.

ER: What was it like the first time? I remember even just, I grew up in San Diego, so not nearly as far as Turkey and yet, even for me, the first time that I drove around Silicon Valley and saw the headquarters of all the companies that I had had all these relationships with as a customer, as a developer, it was a profound thing. What was it like for you?

EB: It was a very interesting experience as in, it wasn't what I was thinking Silicon Valley is. I thought I would come and there would be just massive buildings, really like technology infrastructure and squeeze everybody. So, I was imagining it more like an Asian, Hong Kong type of city.

ER: Almost like Blade Runner.

EB: In my head I was like Silicon Valley, and I came in and it was a bunch of suburban houses.

ER: Yeah. It's very boring.

EB: It was a lot of boring, like visually, but I loved the Valley. I loved the fact that it wasn't intimidating. It was just a bunch of people, smart people, very welcoming, very open to people from other cultures. So, the surprise was how un-intimidating it was for a newcomer. But I think the, I just quickly adapted and I realized it wasn't just about writing software, things like customer service, marketing growth, those ideas were ... they were very refreshing, because those ideas are very unique to Silicon Valley, or back in the day, they were very unique to Silicon Valley.

ER: How would you contrast the difference? I think one of the things that we, who are, you have the privilege of being here, in America, in California, in Silicon Valley. We don't even see and appreciate the water that we swim in, so sometimes it takes an outsider with an outsider's eyes to help us understand what is distinctive about it. So, what were those differences that caught your attention when you first immersed yourself in the ecosystem here?

EB: I was really shocked at how collaborative the whole ecosystem was. I mean, I was observing our founder, Simon, he would ask for help and they would meet us and just give us all the information we needed. So, it was weird like, you could just literally ask help from anybody and they will try to help. And yeah, I think most other countries have more a cynical approach to businesses and every company is thinking of each other as a competitor. So, Silicon Valley just felt super open. It also made me think that there was opportunity for people, for newcomers to come in and be successful there. But then on the negative side, the whole world of raising money, investors, that part felt intimidating. So, there's definitely the feeling that you just, sometimes you didn't belong. Like when you, when essentially I interacted with money, then I felt a little more foreign. But, if you talk to the people in the ecosystem, starting companies that was very open.

ER: That's really interesting. That is a common experience we hear from outsiders that there's only two cultures of Silicon Valley, and when we get into the funding and financing of companies, that that's really where the bias can come in. Was there a particular moment you remember, or a particular story of just feeling like you didn't belong, or someone treated you in a way that you look back now, you realize was about that difference?

EB: I remember two things. One is, occasionally we would sit down at the table, like the small talk is the hardest thing for immigrants. So, you talk about American sports and American sports are also very different than the rest of the world's sports. Trying to adapt that to, that was always a tough challenge for me to just be a part of, trying to be a part of it. I also, I mean, I'm still a man and I just also understand if you don't even enjoy sports, like those small talk subjects were always like the most challenging. I would feel most stressed in the first couple minutes of discussion. So, and then the second thing is like, occasionally, a lot of people would assume I'm a technical, like CTO of a company. So, most people would make the assumption like that I'm not the CEO of the company, even after we started Udemy.

ER: Yeah. I've heard that story from a lot of folks. I'm sorry. You know, we actually have a lot of listeners of this podcast in Turkey. It's actually consistently one of the top countries for reasons I don't totally understand, but I'm curious given that we have a lot of listeners from Turkey, if you have words of advice for them, or if there's anything you'd want them to know if there's folks listening right now, who hope to emulate your footsteps someday?

EB: Yeah. I think most people from Turkey ask me whether they should move to Silicon Valley. Is this the requirement? My answer's really it isn't, that is, since 2005, a lot has changed. The reason we have so many listeners from Turkey is a good proof that the information is more democratized at this point. So, you don't have to be physically in Silicon Valley or San Francisco to honestly get access to the best advice. Also, the funding has also been democratized. I have made several investments in Turkey. I mean, when we first started somebody had asked me in a conference, whether they thought there would ever be a billion dollar company from Turkey.

I guess in fairness, I started Udemy in Silicon Valley, formally. But it is, in fact, a company started by Turkish people. Then, there were also two other companies started in Turkey, which were multi-billion dollar exits. There's another one I’m watching, which is on the path to be a 10 to $20 million company.

ER: Incredible.

: So, I think the last 10 years, the Turkey ecosystem has, I guess like the cost of Silicon Valley has been less about the physical location at this point and more about-

ER: The state of mind.

EB: The state of mind industry we are in.

ER: Yeah. That is a hard thing for folks who've never experienced it directly and who tend to mythologize this physical place. It's not like the sunshine and the low-rise buildings you were describing and the strip malls is the thing that makes it magical. It is a certain ethos about innovation and about people, and that kind of cross cultural collaboration has been emulated now by people all over the world. I think that's actually an incredible positive development.

EB: I think Eric, you've been a part of this idea that if you really democratize the advice and then choose your starting companies and everything else, funding and physical space and talent, those things are actually solved over time.

ER: Yeah. Well, I appreciate you saying that. That certainly has been part of my mission now for a number of years. So, thank you. I’ve got to ask you one question about SpeedDate. I'm really curious, for now and when founders encounter Lean Startup, it's a famous old idea for most folks. Yet when you were at SpeedDate, you were the head of engineering there, I think, at a time, that was before the book had been published before even Lean Startup was especially famous. What was it like to be on the receiving end of that advice at a time when it wasn't very popular??

EB: I was actually, I remember actually the first time the Lean Startup ideas came, and it immediately resonated with me because we had spent 18 months building the first version of Udemy in Turkey, which was a live education platform for learning. We spent all this time building, and we obsessed about a lot of details and we launched it, and we realized there's no way a live marketplace for online learning is going to work. Like literally after 18 months and 10 days, it became obvious that by the time people schedule a session to participate, we were losing 95% of people, and most people were really horrible at live teaching. Unfortunately, we did not have any resources to do take two so I had to shut down the company, move to Silicon Valley full-time. And then we came to Silicon Valley, and we launched the first version of a SpeedDate, I think in seven days total.

We had to raise some seed capital. I literally took the original Udemy live video platform, converted it to live with a dating application. In seven days, we launched the application. Like we literally did not have a forgot password button, and the app has like a million bugs and issues. But we just launch it and started having users and iterated with the user feedback. So, that was the polar opposite of what we had intuitively done in Turkey. Then, I think that was right when you and Steve had this idea of iterating with customer feedback. To me, I just sucked in all of that knowledge, because back in that day, it was like a very refreshing concept. At this point I think it is so mainstream. So, people default.

ER: Yeah.

EB: So, back at the time, it wasn't default. The default was spending two years trying to perfect an application and doing a big launch and demo day, or I mean, TechCrunch Disrupt. The goal was that in the first day of launch, it was getting so much press. It was getting a bunch of customers, and some of those customers would be retained. That used to be the playbook back in the day.

ER: Yeah. It's actually such a short time that this has changed, that a lot of new founders can't believe it, and so I'm glad to get you on the record, just as a testimonial about what it was like, it was only 10 or 11 years ago that we're talking about.

EB: Exactly.

ER: Yeah. It's been a wild time.

EB: And I think one of the things, I'm going to jump to Carbon, but, I think since then actually the concepts have evolved quite a bit, so we are now realizing it's not a single playbook, but when we first studied carbon health, so in healthcare space, it's not easy to just build an application in seven days and launch it, right?

ER: Of course.

EB: Because we were trying to be a technology enabled primary care provider, but to be a healthcare provider, you have to get the license, and you have to incorporate, you have to have a physical location, you have to be able to prescribe medication, you have to be able to order labs, medical imaging, referrals, insurance, billing, the bar is fairly high, but we didn't launch the first version in seven days. I think it took us 10 months to launch the first version, but there is still some similarities.

When we launched the first version, what we tried to prove at first was that patients would actually want this technology driven, mobile app driven, customer experience, and to prove that, we started accepting patients, but we couldn't tell them that the service was going to be free. So we literally did not have an actual billing infrastructure, but we didn't tell people at first, we sort of just acted like we were going to submit their claim to their insurance company. We just never actually did it, just so that we can prove some of the thesis earlier, right?

ER: Mm-hmm.

EB: It wasn't, I guess that wasn't your typical, let's launch an application and mold an iterate model, but then even healthcare does it similar. I think the concept has actually evolved, the methodologies are just getting better, like are changing based on the industry.

ER: Yeah, of course. I mean, I think that's one thing that people miss often is that leadership is a philosophy, it's a set of principles. It has to be translated into specific tactics and strategies that are very context sensitive. And so yeah, when you're in a highly regulated industry like healthcare or finance, the playbook is going to look really different, but the mindset is really what we're trying to cultivate. So I actually think it's really an interesting example of you taking something, that was learned in online education and online dating and then to take it into a much more, if you forgive me for saying, a much more serious problem domain of healthcare. I'm of course really honored to have played even the smallest part in that, that was my aspiration in writing the book originally. But I'm curious why you made that choice to make that switch. How did you... Tell us how Carbon Health came about, why it's a much more difficult problem to tackle? What inspired you to do it?

EB: Honestly, I think from Udemy to Carbon, in my perspective, I had a very linear approach, but I can totally see how it feels non-linear. So we started, I was at SpeedDate, left to start Udemy in Silicon Valley, again in 2010, and Udemy became, I would say, widely successful. We grew quite a bit in the first five years. I was a founder and CEO and Udemy's mission was really making online education more accessible, but broadly I was fascinated with this idea that you can use technology to make something really essential accessible to more people. And I was really thinking Udemy was a great example of techno-optimism. I assume, when you build the platform, a lot of people who are not your typical, ideally college professors can be teachers can make your living, but also they can actually share their expertise with hundreds or thousands of other people.

And then I started thinking about "what other industries need this type of transformation?" And healthcare was really top of the list for me. And then, while I was thinking about it, my mom had this disease called Neurosarcoidosis, so she had this full-body stroke, which was completely unexplained. She's back in Turkey so I moved back to Turkey for a couple of months. My sister is a physician. We were going from doctor to doctor and trying to understand what was happening, and we were carrying thousands of pages of documents, lab results, DVDs with MRI, CT scans, and I think we kind of just jumped around thirteen really kind of specialized physicians.

And there's no sad story here, so the physician number fourteen diagnosed it and the treatments worked fairly well, but I just directly observed that the technology, the tooling, for doctors were really far from what they needed to operate at a high productivity level.

And I actually made a sketch back in 2013, I think, so three years before I started a Carbon. And the story here is, if you're going from doctor to doctor, every doctor would look at these pages, and they just go through hundreds of thousands of pages, and write some things in their notebook, and then they use the notebook to understand what might be happening. And I asked my sister, I said, "What are they writing on their notebooks?" And she said, "They're making a chronology of the case". And my immediate naive reaction was, "Why don't we give the whole content in the chronology format in the first place, if that's how they are thinking about the problem". And I made a sketch about it, how I would design the physicians interface, if I was building a new kind of healthcare software platform, and I just left it sitting around. When my Mom recovered, I came back to Silicon Valley and continued to be the CEO of Udemy.

But that idea did kind of get stuck in my head that the largest, the most expensive resource of any country was one of the worst utilized, and I said somebody should really rethink how a doctor operates, how they communicate with the patient, how that whole concept of care delivery works. And I and a couple friends, we kind of sat down and started making some sketches, and I realized that this was one of the thorny problems, with a lot of regulatory challenges that most funders were not wanting to work at.

There were healthcare funders, but they always wanted to take a slice of the problem, and what I really wanted to do was just bring the strongest technology product physician, kind of clinical-operations people, together to figure out whether we can use technology to make great healthcare accessible to more people. So what really was disappointing for me was that the rare healthcare companies and technology, were using technology, but they were all exclusively focused on young affluent, high-income patients. And I hadn't really seen even a single company who's trying to serve the average retail worker, average teacher in this country. That domain was almost completely unserved from the technology space, and understanding how complex this problem was, I thought somebody should spend 10 years of their lives just obsessing on this problem.

ER: So how did you get from "somebody should really do something about this" to you're going to do something about this?

EB: I initially tried to look for funders to invest, so I met bunch of funders. I didn't realize the intersection of the funding team who's technical enough, was product driven enough, with intersection of the funders who are open to learning this new concept. Just not making any assumptions about how healthcare works, we were willing to just come in and learn from some of the people in the industry, as well, and, the intersections, part of the intersection is people who are willing to work on a thorny problem, right? Like mass market healthcare delivery--I literally couldn't find anybody that I thought was doing it the way I thought it should be done, and I decided that... At that time, Udemy was already at the maturization phase, I think we were a fairly sizable company, and we had a strong executive team, and I thought just hiring a CEO for Udemy, and then me taking on this new challenge, sounded like the right thing to do.

ER: So what is the mission of Carbon Health?

EB: It is very simple. It's all about how you can provide really high quality healthcare to the entire population, and especially focusing on the demographics which are not being served. So really it's just combining this very software driven, very technology driven approach with day-to-day healthcare. But more tactically, we decided that we have to start from the front door of the healthcare system, because that's a consumer decision. So things like primary care, urgent care, virtual care, maybe even mental health, these are decisions that consumers make, so we theorized that if you provide an amazing experience, without increasing the cost at all, you could really dominate as that front door. And if you can become a very sizable healthcare provider in the front of the healthcare system, what happens is the rest of the healthcare system like specialists, and hospitals, and imaging centers, things like that, so those really rely on your patients to really, I mean, to feed their business.

If you become their primary customer acquisition channel, you can now use your influence with the front door of the healthcare system to create a more democratized marketplace for the rest of the healthcare. So that's really kind of the thing, it's a little more complicated, in reality, but it's truly owning the primary care with high quality, low cost, very modern care, and then really trying to pressure the rest of the healthcare system to have the highest, best clinical outcomes at the lowest cost possible.

ER: So take me back in time to right before the pandemic, the start of 2020, where was Carbon Health at that point? How big had it gotten, how many clinics did you open? And just give us a sense of the stage of the company as you wound up facing the pandemic.

EB: So we were in a very interesting phase because I started Carbon Health in 2016, so we were a four year old company, and we had spent the first several years really nailing the unit economics, the customer experience, really this software operations finance, and we had finally come to a place where the numbers were just undeniably working. So we had managed to provide a really modern healthcare experience with very high NPS score, very high retention, while still having a very strong provider experience. And lastly, innovate where we were seeing very good profitability with Medicare reimbursement rates. So essentially we had finally hit the benchmark, which I considered as the benchmark, to just start scaling the company like crazy. It was several years of optimization and then we were actually scaled at that moment. I think January of 2020 was when we said, "Okay, now we are going to just take this and scale it as fast as humanly possible".

And I think we had seven clinics just at that moment, but we also had a pipeline of 20 clinics for 2020, and the pandemic hit us actually fairly early because we have the system that takes the details of the patient's problem. And, when we started seeing the news from China, we put some additional questions to screen for COVID risk, and, as early as January, we started seeing patients who were coming from, literally from Wuhan, China to California, and they were coming to our clinics with respiratory symptoms. So we caught this really early and then started really getting into this crisis management mode in January, so by the time it was considered a pandemic, in March, we had decided that this is going to be our focus for the year, for the foreseeable future.

ER: Did I read correctly that the first case in California was found in a Carbon Health clinic?

EB: So it was one of our patients, which we couldn't get tested, but then, eventually, because CDC, well only CDC was providing testing at that point. With that patient, we were monitoring a lot of patients, not just one patient, we were monitoring thousands of patients remotely. So we were asking them to stay at home, we would actually check back with them daily, and then, if their symptoms get worse, we would actually then suggest to go to other places. So I think one of those patients went to ER and then got tested by the CDC at a community hospital, and was considered one of them. I think it was considered the first community spread patient.

ER: Talk a little bit about your mindset as this information was rolling in. This was before the general public really had an awareness of this, and obviously the American response and kind of our level of alertness to this crisis was very slow. What was it like having that information? How did you know what actions to take? What did you view as your guiding light as you started to navigate those difficult waters?

EB: So there was a lot of uncertainty, I would say the CDC guidance honestly was very weak. It didn't really tell us anything substantial about what we should be doing as a healthcare provider, and there were some people who, in the company even, who said, "This is going to be a massive problem. We have to just put all of our resources to fight this pandemic." And then there were all sorts of people who thought this might be a three-month kind of problem, and it might be gone by the summer, and I had to make the final call as the CEO. And there was also just massive PPE shortage. We were literally short of N-95 masks, and I just discussed with our clinical leadership and we made the decision to just be on the front lines of this pandemic and offer testing as soon as possible.

Essentially, I and our clinical leadership said, "We just have to be in the solutions part of this problem". Because, just going to put that, at that time, most healthcare providers, some, pretty much all of them, were trying to shut down clinics, who'd use ours. They were mostly trying to reduce their risk factors, and they were hoping that the government, the public health departments, would actually take ownership of the response there.

So we decided to just go to the other direction, and I remember talking to my wife about this because I felt really horrible, I guess. I mean, the analogy I give my wife is I said, "I feel like I'm a general sending soldiers to the front lines" because we really did not know what the real risk factor is. And, for all we know we could have, I don't know, 10% of our staff getting infected. And, because, in Italy, the news about healthcare providers were very, I mean, they were not good, but our clinical leadership actually had a lot of experience in front of the original SARS pandemic, back in the day, so they thought that, if you have the right protection, rights, protocols, we could actually safely help our communities. But as I said, I think our clinical leadership made the final decision to just lean in. And I felt horrible. I was so--for our employees, I mean, I just, we started like trying to, I just said like the entire team now your job is to support our frontline workers. And as the situation became more and more dire around the end of February, and we had this executive meeting and our head of product Ayo said, "Let's just think about what we wish we would have done if we knew that this is going to be a devastating pandemic.” And I had brought it actually a list of like really crazy ideas for the meeting. And my goal was just to...kind of inspire some other ideas. And I kind of had this list of 10 crazy ideas that we could consider if you really want to kind of take this pandemic very seriously. And I think what happened is over the next 18 months, we have implemented every single one of them.

ER: Give some examples.

EB: So the first one was just building, the simple one, was building a risk assessment system to evaluate Covid risk. The second one was I think, just buying a bunch of trailers and converting them into mobile testing centers and going to underserved communities. Another one was partnering with companies to help them operate safely, if they are essential companies. I think that another one was really kind of partnering with local governments on this part and trying to help them. And one of the most immediate things was going to residential. Not residential, assisted living centers and registered nursing homes and try to screen them on a weekly basis. So, I mean, in retrospect these look like straightforward ideas, but I think the only thing we haven't done in that original list was kind of building a makeshift ICU center. 60 hospital ICU beds really, like gets completely booked so we were considering to work with the military to be able to build a kind of a portable ICU kind of system. So I think like aside from that, everything else became necessary. Actually one more was doing at-home testing. All those kind of original, crazy ideas became reality like in the last, next year or so.

ER: If you could go back in time and give yourself a piece of advice from those early days, is there something now, you go back, and you wish you had done or had done differently?

EB: I think the only thing that we didn't anticipate was how long this was going take. So, we funneled off our resources into responding to the pandemic, assuming it's going to, it was going to be a three to six months problem. And then after, I guess like, a little more than a year, we are in better shape. But I honestly don't think we would have done much differently because it's just like, there were certain solutions we built that we realized wasn't the most important solution, but like, I think our attitude was correct because we just decided to take this more seriously than pretty much anybody else in the country.

ER: So fast forwarding a little bit, you wound up becoming a critical part of the vaccine infrastructure and

EB: So the story of vaccine, our involvement with vaccine actually just started last summer. So when we, when I was observing how to counter how we were so unprepared to do testing on scale, then seeing that vaccines might come in sooner than people expect. So I had actually written an article and I said like, we have to start preparing the infrastructure for vaccines like from today. We should just have to build them as if the vaccine is going to be ready six months later.

ER: Really smart.

EB: So, and we were opening these pop-up clinics, the trailers. And my goal was that when vaccines were available, we will be using pop-ups as the kind of core vaccine distribution infrastructure. But when the vaccines actually came out, there were two things that like, I hadn't calculated. Number one, the storage requirements are very strict, like shipping them at minus 80 celsius was not going to something you can do in a small clinic or pop-up. And the number two is for especially older high-risk patients, you had to, you had to monitor them for 30 minutes. So, I realized that vaccinating somebody takes two minutes, but the monitoring is 30 minutes. So your main bottleneck is going through the physical space. So we quickly pivoted from this mobile clinic base model to like, thinking about how we could do mass vaccination.

And I sketched something over the New Year's. And I think early January, the vaccine rollout in California was really bad. I think California was one of those kind of...diverse states in terms of the vaccine distribution and Los Angeles was particularly struggling. It was a fairly sizable city and there was a state launch system, which was not working very well. And they were really struggling. So we quickly showed them what we thought should be available to do vaccine distribution on scale. And, to the credit of the mayor's team and the LA fire department, they saw what we had built and sketched, and they said, "What's the fastest you could imagine launching this?"

And we asked them for two days and two days later, two days after our first meeting...we launched a website to just get people to sign up or get joined to the waiting list for getting vaccinated in LA and then, we launched the front-end scheduling system first. And then like in seven days after we built our first version of the provider platform.

And this is not completely from scratch to be fair. Like, so, because we own our entire technology stack, we had all the infrastructure for scheduling and triaging patients like the private platform, registering medication administration. We already had the infrastructure, we just built a new, a skin on top of our existing software platform. It's like we had a bunch of those pieces, but we had to bring them in a different structure so that it's the most efficient you can imagine. Because the staffing was very limited back in that time. So, yeah, so we launched this and then seven days after the original handshake and launch into a scheduling website, we helped launch Dodger Stadium, which was the single largest mass vaccination site in the country.

And that was another, just like amazing example of, I think like being lean and just iterating because I had to go there with 30 or 40 people from our technology team: executives. We all just physically went to Dodger stadium, stayed there. We actually like, built some of the software on the ground there. And then the first version was working fine. It was better than what existed before Carbon, but it was far from perfect. It was not very accessible. It was not a great first. I mean, as an example, if you're using a landline, you couldn't use it because we required SMS verification.

So we knew about the issues when we launched it, but it was still better. And then every day since mid- January, we have been making iterations on the platform. After a couple months, I would say like, it's now like a state of art vaccine distribution platform.

ER: Do you know how big of a fraction of the California vaccine rollout you guys have been?

EB: I think we have done 1.3 million vaccines.

ER: Wow.

EB: California should be 30 million. So around 4%. And I would say like, we have capacity to do at least three times more than what we did if we had enough supply. So there were, there was definitely a supply shortage. So we had capacities like, we had, we built enough to do 40,000 vaccines a day. Everything went well but then like around like one week ago--until like last week, we were barely able to kind of handle the demand and supply was the main constraint. I think last week it changed from supplies to the demand.

ER: So we've been talking about getting to that tipping point now for, for a couple of months, you know, that some point it would, we would switch from demand to supply constraint. So what do you think needs to happen next? Now that we're going to enter into a period of being demand constrained, what's your view about what needs to happen to eventually reach herd immunity?

EB: I mean, what has to happen is...we need to vaccinate roughly 30% more of the population. I think give or take like 50% are getting vaccinated or are-

ER: We have to get to about 80%, right?

EB: We need to get around 80% because 15% of the population is, strictly like, against vaccination. I think those are really hard to convince otherwise. And there's another 4 to 5% which are immunocompromised. So they can't get the vaccine or even if they did, like, it was, it's not going to be as effective for them.

So, if you really completely want to go back to normal, like no masking, no social distancing, if you want to forget about this, we roughly need 75% of the population to have to vaccinate them.

So, really the challenge right now is, how do we convince that remaining 25%? And I think we have to change our approach here. So the paternalistic approach, where we act like people are being dumb for not getting vaccinated, that's wrong because that's what we are missing is like, there's still an accessibility issue.

And the accessibility issue has gone from physical space accessible to now information accessibility. So you and I are always like following the beats of this. We track the latest developments and we know the CDC needs guidance, we are aware of that. But a lot of the population actually doesn't have this like, as fast of...I mean, essentially they're not on top of the news cycle, as much as we are.

ER: Of course.

EB: We just have to push the information that vaccines are indeed very reliable, fairly low risk, and most people like, the majority of people in the clinicals are all getting vaccinated. That's actually that, like, we really have to push the information to the rest of the population who are not actively like, on Twitter, kinda following the news cycle.

: Are you optimistic that we can reach that threshold?

EB: I am optimistic, but I think the remaining 20% is going to take a lot of initiative from not just local governments and Department of Health and clinical providers, but we will also need the help from other community leaders, maybe religious groups. We will need help from celebrities, athletes, sports teams. To just really help the public pass the message. There's definitely a lot of confusing information. So, people need to hear this from the people that they trust. And honestly like, clinical or the CDC or the local governments are not always the ones that the entire population trusts completely. I mean-

ER: Yeah. Well, we live in an era where we're trust in institutions is at an all time low, really with the exception of the private sector.

EB: Exactly. I think the--I mean...unfortunately like more people are getting medical advice from Joe Rogan than Fauci at this point.

ER: Lord help us. Well, you know, it's interesting though, we had Ron Klain on in an earlier episode of this podcast from before the election even, and for those who haven't heard, it was fascinating now to compare what's happened to his predictions and his philosophy.

But one of the things that he has been going on about quite a bit in public is the idea that there was going to be a whole of government response to COVID and people kept asking him, "Well, is that, does that include FEMA? Does it include the military?" And he kept being like, "What part of whole of government are you not understanding? We're going to mobilize every resource and asset," leaving aside the question of how well they've done. You know, obviously, the jury is still out, but it seems like it's going pretty well.

I kind of feel like we are still missing the kind of whole of society response. Like we're now at a moment where, you know, elites and leaders of companies, of communities, of religious leaders, like all of us who have a privileged position in society, it seems to me ought to be coming together to try to reach this goal. It's not just so that we can have the convenience of the old normal back. It's much more so that we're talking about still quite a lot of lives to be lost or saved.

And I wonder if you have a view kind of having been on the front lines, if you had an ask, you could say, "Hey, if there are people out there who are listening to this right now, what would you want them to do to mobilize and to help even now in this late date?"

EB: I would say we are in the phase where, now everybody can have a sizable impact on this. So because when it's all about just a hesitation to get vaccinated, or maybe not evaluating the importance of it. So I think this is where everybody can play a role.

Like three months ago, the person in a church, like, was not very relevant to the response because it was all about scaling distribution and administration of vaccines. So companies like Carbon Health had a more central role. But at this point, when you, when it comes to convincing and educating the population and like, this is one place where we have to work as a whole society. And honestly, when people look at the response in Asia that's one of the differences. I think like they have worked really as entire society together to solve this problem.

I think that United States, it's still a bit more fragmented. There's a lot of, this problem has been just very unnecessarily politicized. So, and now we couldn't have discussions about, "Should you shut down? Should they just reopen everything and schools?" Like, I mean, I know a lot of people have opinions about these subjects, as they should. But, that kind of inner fighting is really becoming an obstacle when we are about to solve the problem completely.

ER: Yeah, this is, I mean, it's literally one of those unite or die moments. You know, if we can find the unity, if we can find a sense of common purpose we can beat this thing. But if we don't all the energy we face, we spend on, on ancillary issues, I just, it feels like such a waste.

EB: Yeah. Look, I was always very optimistic about just beating the pandemic because this must be the first time where major total civilization just like worked towards the same goal.

And so we dealt with that. We had to be found as more where we were all united in fighting against this pandemic and this virus. And I think we made like a ton of progress and we are about to knock it off for good. But, it's just like, we need a, like, it's just, it's the last quarter, but we still have to play the last quarter. Because otherwise this is just going to just stay as endemic, it's going to be persistent and people will, like people will learn how to live with it, and that might be okay, but you know, what would it be better than learning how to live with it? It's just really eradicating it.

ER: Indeed. I don't know why, maybe this will seem cheesy, but I have had Lord of the Rings on my mind quite a bit lately. And this idea that if we can find common purpose and not waste our energy, we can defeat this thing.

It's really magical. And so for those who kind of have been on the sidelines or have been knocked out of the fight, you know, I always think about, and we don't have Sir Ian McKellen here to deliver the line properly. But the idea that when Gandalf returns, he says, like, "I come back to you now at the turn of the tide." And this is that moment. So any one of you can be Gandalf the White and be a hero now in the fight to get us through this last push. And if we do that, if we come together to make that happen, think about the story we'll be able to tell our children and grandchildren about a world that is free of this kind of disease. But also hopefully not just COVID-19 is eradicated, but we learn what is necessary to defend ourselves against these kinds of threats in the future too.

EB: Yeah, absolutely. And, to be more practical, if you're an employer, if your employees just- give them time off to get vaccinated.

: Yes, please, please do that.

EB: I think one of the things we are observing is if you're affluent just a lot easier for you to take time off go get vaccinated. So that's number one, and just good knowledge for everybody, at this point there's so much vaccine and supply you can just go get vaccinated same day. It really will take less than an hour, just drive somewhere. At this point they no longer even require scheduling, so you could just come in, register yourself, onsite, get in and out in half an hour or so. So that is easy. So, and also if you know people who don't have a car who needs some maybe companion to get vaccinated, just do all those things. If everybody brings one or two people to get vaccinated, we'll be able to just honestly do large gatherings faster.

But otherwise I'm slightly worried that- There's a fatigue in dealing with the pandemic, and if you just assume it’s completely gone and revert that, there will at least be one more comeback. It is going to come back. Because right now the kids are doing well because we are still in semi quarantine mode. But if you had reopened completely without the remaining...

ER: Yeah, yeah. If we leave the job half done, we will certainly regret it. And we have seen that pattern through the pandemic multiple times, how many geographies, countries, cities have had a really effective response to the pandemic during some phase, and then relax, because they feel like they won. It's beaten. And conversely ones that have had really disastrous responses sometimes bounce back much stronger for the next wave because they really learn their lesson. So we have this one chance, this one chance to get this right. And now is the moment to be in action. And I know the fatigue is real and I know people have struggled, but one final push and we can eradicate this for good.

EB: And by the way, I'm not saying that like we should continue to quarantine. At this point it's safe to be outside and have dinners and a haircut, and you should just enjoy these things. But if we completely divert, it's going to come back because we haven't vaccinated enough people yet. But if we do this in conjunction with also getting our neighbors and our friends who are maybe just feeling lazy. It's just, if you have a friend who's not vaccinated, just get together, go get vaccinated. If you do these things while we are reopening, I think it will be fine if we do not get the remaining 20, 30%. But, I mean the remaining 50%, but I'm assuming that there is 15% that we want people to reach out to us. And so we need to get essentially 60% of the remaining people or so. But if you open 100%, if you forget about the virus completely, it is going to come back. But we slowly transition and do our job, then I think we can just forget about this problem, like next year, or even like by this fall, we should be able to really just act as if COVID no longer exists.

ER: That would be truly a miracle. Talk a little bit about how you've balanced and how you see yourself balancing the work of this COVID response with the core business of carbon health. Has that been a challenge and have your investors understood and been able to comprehend that you have this dual mandate? What's it been like trying to do that balancing act?

: It certainly has been difficult, and there's no perfect answer here. But luckily our board and investors have been very supportive. So they generally know what we are on a daily basis. So we understand, but the company has grown quite a bit since the pandemic started. So I think we were roughly 200 people in the beginning of 2020. And if COVID never happened, you'd like to be six or seven hundred by the end of the year. But instead we have gone from 200 people to 2000 people in 14 months. And I think we might be one of the fastest growing companies who actually have physical operations, and some of it has been really good specific vaccine rollout testing type of efforts. But you have also gone from 10 clinics, 13 clinics, to 67 clinics right now.

So it's a dual mandate and we keep balancing resources. For example, when vaccine rollout was really problematic, we put almost all of our efforts to it for at least a month. And then after a month we were able to pull back resources to like primary care and our more longer term health care initiatives. So again, it's a constant kind of balancing act. It's all about if there's a truly urgent problem in our communities, we feel like we have to in response. If not we tried to invest in more longer term core business.

ER: What do you think is the future of public health in this country, especially how do you see the relationship between the government and private industry? You've kind of had to straddle both during this response. Has it changed your view about what public health might look like in the future?

EB: It has certainly changed. So, we are now formally building a public health division within the company. So if you think about Carbon Health, so we have our consumer division working with clinics direct to consumer, and then we have an enterprise division working with companies, and I'm now formally incorporating a public health division. We'll have a GM. We'll have dedicated product people, engineers, operations support, all of those things because I was able to observe, observe firsthand that to the traditional model where the government and local government puts a big RFP and then bunch of contractors respond to that RFP, that model is not working well because it just like the RFP ends up really convoluted and bloated, and then the contractors are building really software they think as a one-time software they have to build. So they don't think of this as a living organism.

So what we are trying to do differently at Carbon is, I especially want to replicate what we did for vaccine rollout and some other public health problems. So we want to be technology but a public health partner. And there are- If COVID completely goes away, there are a lot of public health challenges from healthcare in rural areas to healthcare or maybe unsheltered populations. Essentially, if we want to fix healthcare for the most underserved communities, it's very hard to do that purely as a for-profit entity. And we actually kind of saw that there's nothing wrong with a private for-profit private company to partner with the local governments and nonprofits to focus on all the same problem. And I think that that type of partnership worked extremely well when we helped with the vaccine rollout with multiple counties and cities. And I think that was like a really magical set up. I want to continue that set up for other public health problems in the future.

: If we have some founders who are listening, any issues or problems in the space that you have learned about or noticed since you've been doing this that you'd encourage them to work on?

EB: So I would say even in places like Los Angeles county, there are big healthcare deserts, places where you don't have good healthcare access in 50 miles. And that problem is not solvable purely from virtual care, so you need still some physical access points. So there's some kind of outstanding problem. I assume I would say working with schools- In the school systems, there's huge disparity between the resources of different school districts, and some of them require more like local governments help. So yeah, honestly, I would just generally suggest that this whole public health project is not something exclusively for large defense contractor-type companies. Even smaller startups can actually operate fairly well, just help- as long as they listen to the local governments and understand their problems, because some of the best solutions I've seen in COVID related public health efforts, they're actually coming from technology startups. They were not Google, Amazon coming in to save the day type of issues. If anything, actually, I was really disappointed with the response from large companies. I don't think those massive companies have made a significant role in the pandemic, but then some smaller tech startups, smaller other entities have actually probably done it a lot more than the kind of Googles of the world in this pandemic response.

ER: It definitely was surprising. I spent a lot of time on the phone with companies large and small the past year and yeah, the results absolutely speak for themselves. So what do you feel like the longterm impact of the crisis will be?

EB: I think the silver lining is like 20 years later, we will actually be in a far better position because so many more people are now entering the healthcare space. There are a lot more strong technical product people coming into the healthcare space. So it's really between the funding, the interests from talent- I think actually it might end up becoming a net positive for healthcare because of especially the increased number of people working in the space. You were not very involved in public health or healthcare in general. You're now putting a lot of minds into how technology companies can help you out. So I think that is actually very promising. Definitely increased usage of virtual care. But I think what you're seeing is that the omni-channel care idea is going to become more dominant. Essentially patients are now expecting their healthcare providers to work with them both online and offline. So that fragmentation, I think, is going to mostly disappear in the future because now every single healthcare provider has learned how to do virtual care. And then I think they will continue to do this as a part of their practice.

So, lastly I think some of the industries which went digital first won't be coming back. I'm really hoping a lot of investor meetings will now be virtual first, so you won't have to travel as much, which might cause the capital to be more democratized around the world. I think there's interesting implications for healthcare and also the broader industry.

ER: Absolutely. Well, Eren, I want to say, thank you first for coming on and sharing the story with us. As well, thank you for all of the work that you've done as a founder and as a leader, especially here in California during COVID. But also how lucky we feel that you chose to immigrate from Turkey and to do what you have done here in the valley. It's just been awesome to get to see all come together for you. So congratulations and thank you.

: Yeah. Thank you very much, Eric. And honestly, I'm mostly a spokesperson for the frontline role because we have the people work in the product teams and technology teams and support teams. They will have done all the work. I'm merely just helping get people in the same direction. So, but thank you very much.

ER: Well, a true servant leader as we always look for. Let me ask you one final question, which is simply how do we get out of the crisis?

EB: I think we are close. We really need to just stop politicizing this a little bit and realize that we are about to be all over with it. And everybody's on the same side here. Increase vaccine information and reduced the current things, but still have some minor protections until we are fully over the hump. And I think just to kind of really just like work as a whole society just together for the next- I think, three more months and we are completely over this problem.

ER: Eren, thank you so much for coming on.

EB: Thank you very much, Eric.

: This has been Out of the Crisis. I'm Eric Ries. Out of the Crisis is produced by Ben Erlich edited by Zach McNeese and Sean Maguire. Music composed and performed by Cody Martin. Hosting by Breaker. For more information on ways to get involved, visit helpwithcovid.com. If you or someone you know, is leading an effort to make a difference. Please tell me about it. I'm at E-R-I-C-R-I-E-S on Twitter. Thanks for listening. Please rate and subscribe wherever you like to listen.

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